Basic Information
| Provider Information | |||||||||
| NPI: | 1609952233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PURITY DIALYSIS CENTERS, INC | ||||||||
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| OtherOrganizationName: | MENOMONEE FALLS DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 SUN VALLEY DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | DELAFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530182318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626464162 | ||||||||
| FaxNumber: | 2626462498 | ||||||||
| Practice Location | |||||||||
| Address1: | N87W17301 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530512760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622539768 | ||||||||
| FaxNumber: | 2622539870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | WALDRON | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2626466426 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 52D0988770 | 01 | WI | 52D0988770 | OTHER | 42054100 | 05 | WI | MEDICAID |